Physical Examination & Health Assessment: NSG 211 Quiz 3 - Heart and Neck Vessels Flashcards

• It's the area on the anterior chest directly overlying the heart and the great vessels.
• It's located between the lungs in the middle third of the thoracic cage (aka. mediastinum).
• It extends to from the 2nd to 5th ICS and from the right border of the sternum to the left midclavicular line.

1. Pericardium
2. Myocardium
3. Endocardium
4. Atria
5. Ventricles
6. Valves
7. Chordae tendineae.

• Pericardium
• Myocardium
• Endocardium

• It's a tough, fibrous, double-walled sac that surrounds and protects the heart.
• It has 2 layers that contain a few mL of serous pericardial fluid.
  • Ensures a smooth, friction-free contraction of the heart muscle.
• It's adherent to the great vessels, esophagus, sternum, and pleurae.
• Anchored to the diaphragm.

• The muscular wall of the heart that does the pumping.

• The thin layer of the endothelial tissue that lines the inner surface of the heart chambers and valves.

• Pumps blood into the lungs.

• Pumps blood into the body.

• An impermeable wall, aka the Septum.

• A thin-walled reservoir that holds the blood.

• The thick-walled, muscular pumping chamber.

• Prevents back flow of blood.
• Unidirectional (can only open one way).
• Open and close passively in response to pressure gradients in the moving blood.

• Two Atrioventricular (AV) valves:
  • Right AV = Tricuspid valve
  • Left AV = Mitral valve (aka bicuspid).
• Two Semilunar (SL) valves:
  • Pulmonic valve
  • Aortic valve

• They both separate the atria (atriums) and the ventricles.

• The RA and the RV.

• The LA and the LV.

• The AV valves open during the heart's filling phase.
• Allowing the ventricles to fill with blood.

• During the pumping phase, the AV valves close to prevent regurgitation of blood back up into the atria.
  • The SL valves open to allow blood to be ejected from the heart.
• The papillary muscles contract at this time, so that the valve leaflets meet and unite to form a perfect seal without turning inside out.

• Between the ventricles and the arteries.

• Right side of the heart.

• Left side of the heart.

• Because there are no valves between the pulmonary veins and the LA.

• Because there are no valves between the Vena Cava and the RA.

1. Into the RA through the inferior vena cava.
   • Superior vena cava drains venous blood from the head and upper extremities.
2. From the RA, venous blood flows through the Tricuspid (AV) valve to the RV.
3. From RV, venous blood flows through the Pulmonic (SL) valve to the pulmonary artery to be delivered to the lungs.
4. Lungs oxygenate the blood and then the it returns to the heart through the pulmonary veins into the LA.
5. From LA, arterial (oxygenated) blood goes through the Mitral (AV) valve to the LV.
6. LV ejects the blood through the aortic valve into the aorta, which delivers it to the body.

1. Diastole
2. Systole

• Ventricles relax and fill with blood.
• 2/3 of the cardiac cycle.

• Heart contacts and blood is pumped from the ventricles and fills the pulmonary and systemic arteries.
• 1/3 of the cardiac cycle.

• It's the first passive filling phase.
• The ventricles relax and the AV valves (Tricuspid and Mitral) open silently.
• The pressure in the atria is higher than in the ventricles, so blood pours in rapidly.

• Aka "atrial kick."
• Toward the end of diastole, the atria contract and push the last among of blood into the ventricles.
• It causes a small rise in left ventricle pressure.

• During ventricular diastole.

• Ventricle pressure is higher than the atria pressure.
• The AV valves swing shut, preventing regurgitation.

• The first heart sound.
• Signals the beginning of systole.
• The closure of the AV valves.

• A contraction against a closed system (all four valves are closed) works to build up pressure inside the ventricles to a high level.

• Briefly all four valves are closed when the ventricular walls contract.
• Pressure builds in the ventricles until it finally exceeds the pressure in the aorta.
• Aortic valve opens and blood ejects rapidly.

• Pressure falls when contents (blood) is emptied from the ventricles.
• When it falls below the Aorta pressure, some blood flows backwards toward the ventricle.
• This causes the aortic valve to swing shut.

• The closure of the SL valves.
• Signals the end of systole.

• After systole, all four valves are closed and the ventricles relax.
• The atria are filing up passively with blood delivered from the lungs.
• Atrial pressure is higher now than the relaxed ventricular pressure.
• Mitral (AV) valve opens and diastolic filling begins again.

• The tricuspid component (T1)

• Pulmonic closure (P2)

• First heart sound.
• Loudest at the apex of the heart.

• Second heart sound.
• Loudest at the base of the heart.

• The intrathoriacic pressure is decreased = more blood is pushed into the vena cava.
  • RV stroke volume increases, prolonging RV systole and delays the pulmonic (SL) valve closure.

• A greater amount of blood is sequestered in the lungs during inspiration.
• Momentary decreased return amount to the left side of the heart = decreasing LV stroke volume.
• Decreased volume shortens LV systole and allows the aortic (SL) valve to close earlier.

• When the aortic valve closes earlier than the pulmonic valve significantly, two components are heard separately.
• Split S2.

• Diastole normally is quiet, but in some conditions ventricular filling creates a vibration that could be heard because the ventricles are resistant to filling during protodiastole.
• Occurs after S2 when AV valves open and atrial blood first pours into the ventricles.

• Occurs at the end of diastole (at presystole) when the ventricles resist filling.
• The atria contract, pushing blood into a noncompliant ventricle, creating vibrations that could be heard.
• Occurs just before S1.

• Normally blood circulation through the cardiac chambers and valves is quiet.
• Some conditions create turbulent blood flow and collision currents.
• Like nosey water flow over a pile of stones or a sharp turn in the stream.

1. Velocity of blood increases (flow murmur).
   • Ex. In exercise or thyrotoxicosis.
2. Viscosity of blood decreases.
   • Ex. In anemia.
3. Structural defects in the valve or an unusual opening in the chambers.
   • Ex. Narrowed valve, incompetent valve; or dilated chamber, wall defect.

• Angina.
• May also have pulmonary, musculoskeletal, or GI origin.

• Severe chest pain.
• Occurs when the heart's own blood supply can't keep up with metabolic demand.
• Feels like a squeezing "clenched fist."

• Diaphoresis (excessive sweating)
• Cold sweats
• Pallor
• Grayness
• Palpitations
• Dyspnea (SOB)
• Nausea
• Tachycardia
• Fatigue

• Dyspnea on exertion.

• The need to assume a more upright position to breathe.
• Note the exact number of pillows used.

• Dependent when caused by heart failure.

• Is worse at evening and better in the morning after elevating legs all night.
• Bilateral, but unilateral swelling has a local vein cause.

Coronary artery disease.

• A sustained forceful thrusting of the ventricle during systole.
• Occurs with ventricular hypertrophy as a result of increased workload.

• At the sternal border.

• At the apex.

• At the 2nd, right ICS.

• At the 2nd, left ICS.

• Left, 5th ICS near the sternal border.

• Left, 5th ICS at MC line.

• Left, 3rd ICS near sternal border.

• No, an innocent murmur or systolic murmur may occur with a normal heart.
• But a diastolic alway indicates heart disease.

• Barely audible, heard only in a quiet room, with difficulty.

• Clearly audible, but faint.

• Moderately loud, easy to hear.

• Loud, associated with a thrill palpable on the chest wall.

• Very loud, heard with one corner of stethoscope lifted off of the chest wall.

• Loudest, still heard with entire stethoscope lifted just off the chest wall.

• Rhythm varies with the person's breathing, increasing at the peak of inspiration and slowing with expiration.
• Normal in young adults and children.

• 50-100 beats per minute

• The cardiac output is inadequate causing blood to not effectively pump through the pulmonic or aortic valves.

• Left CHF
• Right CHF

• Objective
  • Patient c/o Fatigue & Dyspnea.
• Subjective
  • S3 may be present.
  • Rales/Crackles may be present on exam.

• Increase in the Jugular Vein Pressure
• Dependent peripheral edema
• Weight gain
• S3 may be auscultated on exam.

• Caused by ischemia (lack of oxygen) to the myocardium resulting in infarction (death) of the cells.

• c/o crushing chest pain
• With pain and numbness down the left arm.
• Diaphoretic
• Dyspneic
• Pain does not improve with rest.

• c/o fatigue
• Abdominal bloating/discomfort
• Jaw pain
• Dizziness

• Weak, thready pulse.
• Heart sounds may be distant.
• Hypotension may be present.
• Cyanosis may be present.
• Irregular heart rhythm (Dysrhythmia).

• Inflammation of either the parietal & visceral layers of the pericardium or the outer myocardium (Wilson & Giddens, 2009).
• Can be a result of an MI, cardiac surgery, infections, etc.

• O: Pt. c/o chest pain.
• S: Friction rub auscultated.

• Persistence (non-closure) of the channel joining between the L pulmonary artery to the aorta.

• S: None
• O: Blood pressure has a wide pulse pressure and bounding peripheral pulses from rapid runoff of blood into low-resistant pulmonary bed during diastole.
  • The continues murmur heard in systole and diastole is called "machinery murmur."
  • Holosystolic & holodiastolic murmur auscultated.

• Abnormal opening in the atrial septum (open communication between atria), resulting usually in left-to-right shunting, which causes a large increase in pulmonary blood flow.

• S: Defect well tolerated. Children and young adults have mild fatigue and DOE.
  • May have weight gain as shunt increase.
• O: Systolic murmur (II-III/VI), ejection, medium pitch, best heard at base in 2nd, left ICS.
  • Murmur not caused by shunt, but by increased blood flow through pulmonic valve.
  • Sternal lift often present.
  • S2 w/fixed split, with P2 louder than A2.

• Abnormal opening in septum between ventricles, usually sub-aortic area.
• The size and exact position vary.

• Blood shunting through ventricular septum from left-to-right.

• S: In infants with large defects:
  • Poor growth
  • Slow weight gain
  • CHF (severe condition)
  • Feeding problems
  • DOE
  • Frequent respiratory infections
• O: May have a loud, harsh holosystolic murmur with small shunt.
  • Best heard at the left sternal border and may be accompanied by thrill.
  • With a large shunt (defect), a soft diastolic murmur.
  • Heard at the apex (mitral flow murmur) due to increased blood flow through mitral valve.

The number of blocks walked or stairs climbed to produce pain.